Job Description

Description

The Care Coordinator (CC) may be required to deal with patients and, if appropriate, their carers, before or after the patient's consultation with a clinician or other healthcare professional.

The CC's role requires them to be able to work closely with the patient and their clinician or other healthcare professional and understand the roles of, a variety of different people working in the practice and across the PCN.

The CC will be involved in coordinating patients' healthcare and directing them to the appropriate service to ensure that they get the most suitable care from whatever health or social care provider is appropriate

You may be given a caseload of identified patients and be required to ensure that their changing or present needs are addressed by taking into account local priorities, health inequalities and/or population health management risk stratification.

We are seeking two full-time Care Co-Ordinators, one will be based at our surgery on Crystal Palace Road SE22 9EP and the other at our Chadwick Road Surgery SE15 4PU.

Key Responsibilities

The following are the core responsibilities of the care coordinator. There may be on occasion, a requirement to carry out other tasks; this will be dependent upon factors such as workload and staffing levels:



a. Support Quality and Outcome Frameworks, PCN and other LES and DES specifications

b. Maintain and develop engagement with appropriate DCM colleagues and encourage 'best practice'

c. Act as the first port of call for patients, in their caseload in relation to their care.

d. Support and Manage clinical call and recall

e. Bring together all of a person's identified care and support needs, and explore their options to meet these into a single personalised care and support plan (PCSP)

f. Working across DCM Primary Care to manage the needs of patients in Care Homes, supported accommodation or trying to remain living at home

g. Performance targets - Ensure all patients receive enhanced care in a timely fashion and any other aspect of managing the patient facing service.

h. Support with the performance/KPIs dashboards.

i. Undertake audits for dashboards/KPIs


j. Support with any admin related task to the central team

k. To work as part of a multi-disciplinary team in a patient facing role to assess and respond to patients and colleagues using their expert knowledge

l. To be responsible for arranging assessment of new patients with subsequent production and completion of individual care plans by appropriate clinicians

m. To provide personalised support to individuals, their families and carers to ensure that they are active participants in their own healthcare and to empower them to take more control in managing their own health and well-being, to live independently and to improve their health outcomes Undertake work in line with PCN directed priorities.


n. Proactively identify and work with a cohort of people to support their personalised care requirements, using the available decision support aids

o. Ensure regular and consistent communication with the referrer regarding patient progress and any complications or guidance

p. Support national screening and immunisation programmes and health checks/screening

q. Monitor referrals to ensure tasks are completed and care delivered by keeping in regular telephone contact

r. Direct liaison with multiple agencies to coordinate care for patients


s. Refer to social prescribing link workers or health coaches were a patient is identified as potentially benefitting from this service


t. To support patient/carer contact roles, and collate patient and carer feedback on their experiences


u. Raise awareness of shared decision-making and decision support tools, and assist people to be more prepared to have a shared decision-making conversation

v. Ensure that people have good quality information to help them make choices about their care

w. Support people to understand their level of knowledge, skills and confidence - their "Activation "level - when engaging with their health and wellbeing, including using the Patient Activation Measure

x. Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing

y. Explore and assist people to access personal health budgets where appropriate.

z. Provide coordination and navigation for people and their carers across health and care services, alongside working closely with social prescribing link workers and other primary care roles.

aa. Support the coordination and delivery of MDTs for their patient cohort


Administrative duties (additional where required)


To process registering new patients, making up notes and entering their details on the computer system. To process new arrivals and deductions. To support with GP Links. Management of the generic inbox Scanning and coding all clinical documents. Using the electronic filing system to complete filing. Dealing with internal and external post To complete admin tasks and support with AccuRx Total Triage To undertake photo-copying and other basic office duties as directed by members of the team. To deal with queries for further information from hospitals or other local providers about patients. To assist in preparing and sending out practice correspondence. Ensure that the system is operational at the beginning of each day & switched on to the answer phone with the correct tape at lunchtime & at the end of each day. Clerical Duties Ensure that prescriptions are handled accurately and efficiently following protocol Monitor incoming electronic test results to ensure prompt review by clinicians Data entry of new and temporary registrations and relevant patient information e.g. smoking status, BP, ethnicity, medication from hospital letters Scan all patient information in computerised record i.e. medical documents, hospital reports and letters as necessary Deal with referrals to primary and secondary care Action tasks set by clinicians via the clinical systems and email Handling of document via clinical systems and practice protocols

Secondary responsibilities

I

n addition to the primary responsibilities, the Care Coordinator may be requested to:

a. Participate in practice audit as directed by the audit lead

b. To be flexible to cover shifts in the event of staff holidays and sickness.

c. Provide lunch cover where needed.

d. To undertake any other duties required by the needs of the practice & commensurate with the post.

e. Following mandatory training - to act as a chaperone when required. To participate and contribute to team meetings and other meetings as required.

f. To undertake training as required including mandatory and statutory training, core skills training and ongoing developmental training.

g. To have knowledge of all Practice procedures.

h. To work in accordance of written protocols.

i. To participate in appraisal scheme.

j. To present a positive image of the practice at all times.

Skills, Knowledge and Expertise

Essential:Excellent communication skills (written and oral) A clear understanding of child protection policy and procedures and commitment to the safeguarding of children and vulnerable adults Clear, polite telephone manner EMIS/SystmOne/Vision user skills Effective time management (planning and organising) Ability to listen, empathise with people and provide person centred support in a non-judgemental way Courteous, respectful and helpful at all times Able to get along with people from all backgrounds and communities, respecting lifestyles and diversity Commitment to reducing health inequalities and proactively working to reach people from all communities Able to support people in a way that inspires trust and confidence, motivating others to reach their potential Ability to use own initiative, discretion and sensitivity Ability to work as a team member and autonomously Good interpersonal skills Problem solving and analytical skills Ability to follow policy and procedure Polite and confident Flexible and cooperative Motivated

Desirable:

The Care Coordinator is enrolled in, undertaking or qualified in appropriate training as set out by the Personalised Care Institute Passed training requirements as outlined by the Personalised Care Institute and fully understands the Personalised Care Framework Experience of working in a primary care setting Experience in use of the Patient Activation Measure (PAM) Good IT skills Good knowledge of MS Office and Outlook

About DMC Healthcare

DMC Healthcare is a leading independent provider of primary care, consultant-led dermatology, radiology reporting, in-sourced routine endoscopy services and MSK community services to the NHS.



We believe that everyone should have the opportunity to achieve healthier outcomes.



Firmly rooted in the NHS and dedicated to excellent patient care for nearly 55 years, DMC Healthcare currently works with 30+ NHS organisations and other partners, treating over 100,000patients each year.


With NHS waiting list pressures, workforce shortages and unprecedented demand, we want to help. We support capacity deficits with a firm eye on quality and robust clinical governance.




Find out more: https://dmchealthcare.co.uk